Effect of older age care reform on hospitals and quality of life
Authors: Daniel Kam Yin Chan, Luke Kar Man Chan
Journal: The Lancet Healthy Longevity (2023)

The 2015 Dutch reform of long-term care,1Maarse JA Jeurissen PP The policy and politics of the 2015 long-term care reform in the Netherlands.Health Policy. 2016; 120: 241-245Crossref PubMed Google Scholar which promotes aging-in-place, provides a classic example of how government policy can impact the lives of many frail older people and how the acute health-care sector is intricately linked to the older age care sector. In The Lancet Healthy Longevity, Joost D Wammes and colleagues2Wammes JD Bakx P Wouterse B Buurman BM Murphy TE MacNeil Vroomen JL Acute hospital use in older adults following the 2015 Dutch reform of long-term care: an interrupted time series analysis.Lancet Healthy Longev. 2023; 4: e257-e264Summary Full Text Full Text PDF Google Scholar performed an interrupted time series analysis using patient-level episodic hospital data to quantitively describe how the reform affected acute hospitalisation rates of older people living in the community, as well as the hospital length of stay (LOS). The results showed a sharp rise of monthly acute admissions immediately following the reform, accompanied by a smaller but significant prolongation of LOS. Many older people with frailty and comorbidities lacked support to adapt promptly enough to the reform, and the municipalities that undertook the home care provider role from the central government also struggled initially.3Kroneman M Boerma W van den Berg M Groenewegen P de Jong J van Ginneken E Netherlands: Health System Review.Health Syst Transit. 2016; 18: 1-240Google Scholar Some people were left with no choice but to present themselves to hospitals, resulting in inability of hospital to cope with the extra workload and an increase in LOS. Using sensitivity analysis, the authors have excluded other possible contributory factors that might unduly increase acute admissions and worsen LOS. These factors included the lag-time in the maturation of service, the 2013 reform of abolishing low care in residential care4Dutch Ministry of Health Welfare and SportExtramuraliseren lichte zorgzwaarte-pakketten.https://zoek.officielebekendmakingen.nl/h-tk-20122013-26-4.pdfDate: 2012Date accessed: April 27, 2023Google Scholar and the 2018 Agreement of Medical Specialist Care5Dutch Ministry of Health Welfare and SportBestuurlijk akkoord medisch-specialistische zorg.https://www.tweedekamer.nl/kamerstukken/brieven_regering/detail?id=2018Z10368&did=2018D31922Date accessed: April 27, 2023Google Scholar. To gauge the overall effect of any health care or older age care reform, comprehensive data incorporating both the hospital and community sectors are vital. For instance, the study found that with time, older people and the health or older age care sectors seemed able to adjust to changes. These adjustments were reflected in gradual normalisation of the hospitalisation rate in the following 4 years, and to a lesser extent, improvement in LOS. However, little is known about what might have contributed to these improvements and at what cost. These improvements might have been due to gain in efficiency (at no extra cost) or at a cost such as the private caring time provided by relatives, or worse, at the cost of the quality of care. It is unclear whether primary care physicians have to work harder to cope with caring for the increase in community dwelling frail, older population to save them from presenting to hospitals. Furthermore, it is also unclear whether extra resources were deployed to support older people staying in their homes privately or via non-government organisations. For instance, many families in Asian countries hire domestic workers to care for frail older adults at home at their own expense.6Liem A Anggraini L Bariyah Nasrikah Lestari E A long overdue recognition: domestic workers as caregivers for older people in Asia.Lancet Healthy Longev. 2023; 4: e129-e130Summary Full Text Full Text PDF Google Scholar Adding to the complexity of data interpretation, care burden in an acute hospital care setting (reflected by LOS) is often shifted to less expensive care settings such as subacute, rehabilitation, or transitional community care programmes. Therefore, the whole episode of care for an individual patient ought to be considered in its entirety to reflect the total impact. Unfortunately, the data provided in the study did not illuminate if such a shift of care burden had occurred. It is also unclear if some older people might have been discharged to residential care facilities directly from acute hospital care without being given a due trial of rehabilitation because of the pressure of increased demands on acute beds, thus resulting in gradual improvement in the LOS after its initial rise. The pursuit of efficiency (eg, LOS) should not be at the expense of quality (eg, mortality, morbidity, rehabilitation opportunity, or early readmission rate) as they are equally important. A comprehensive health economical evaluation balanced with quality assessment is important to inform both costs and benefits.7Sommersguter-Reichmann M Health care quality in nonparametric efficiency studies: a review.Cent Eur J Oper Res. 2022; 30: 67-131Crossref Scopus (4) Google Scholar Last but not the least, the quality of life of individuals affected is important.8Robinson ES Cyarto E Ogrin R Green M Lowthian JA Quality of life of older Australians receiving home nursing services for complex care needs.Health Soc Care Community. 2022; 30: e6091-e6101Crossref Scopus (0) Google Scholar, 9Liimatta H Lampela P Laitinen-Parkkonen P Pitkala KH Effects of preventive home visits on health-related quality-of-life and mortality in home-dwelling older adults.Scand J Prim Health Care. 2019; 37: 90-97Crossref Scopus (21) Google Scholar This aspect is often ignored by policymakers in pursuit of savings. Poor quality of life of home care recipients can occur due to a variety of reasons, which might include inadequate home care support or hospitalisation secondary to falls or errors in taking medications at home, among other reasons. High-income countries along with some low-income and middle-income countries are aging rapidly. Policymakers might resort to drastic action as solution when confronted with complex, challenging situation like deterioration in the cost of caring for older people. The drastic action (2015 long-term care reform) implemented in the Netherlands resulted in profound ramifications for older people, older age care, and health-care sectors. Research that can provide a complete picture of the impact including health economical and quality evaluation would be valuable. Resources are limited but how best to deploy these limited resources to maximise outcomes is a key research priority for older age care. The opportunity of good research topics in older age care are bountiful10Chan DKY Chan LKM Commentary on the opportunities of research in geriatrics and gerontology.Aging Med (Milton). 2018; 1: 7Crossref Scopus (1) Google Scholar and above questions are just some examples. We declare no competing interests. Acute hospital use in older adults following the 2015 Dutch reform of long-term care: an interrupted time series analysisOur findings suggest that the increase in the rate of acute hospitalisation after the reform implementation was temporary, whereas the increase in LOS post-reform appeared to last longer than expected. These results have the potential to inform policy makers about effects of ageing-in-place LTC strategies on health and curative care. Full-Text PDF Open Access